2021 Quality Report




Hospital Quality Improvement Showcase - Marshfield Medical Center, Marshfield

Improving Sepsis Care through Strong Multidisciplinary Collaboration

At Marshfield Medical Center (MMC), the strategic plan is to put quality and safety first. While sepsis is a life-threatening condition, it is well known that early recognition and treatment of sepsis saves lives. To improve outcomes for patients presenting with severe sepsis or septic shock, MMC has taken a collaborative, multidisciplinary and continuous improvement approach to implement CMS’s evidence-based core measures.  

Dr. Ali Al-Hilli and Dr. Zahid, both hospitalists, and Michaela Wilsmann, R.N., M.S.N., clinical quality nurse, co-lead a system-wide sepsis improvement team that meets monthly. This team consists of dedicated and action-oriented members from the emergency department, hospitalists group, intensive care units, pharmacy, quality improvement team, resident physicians and general floor leaders. 

The team continues to improve Marshfield Medical Center’s sepsis work:

  • Through collaborating with information technology, ensuring sepsis bundle compliance is hardwired into practice by reviewing orders.
  • By analyzing outliers and monitoring sepsis data for continued improvement opportunities.
  • Through continuing to provide on-going education for hospital staff using the previously developed tools, which includes pocket cards, posters and computer-based training.
The efforts of the sepsis improvement team have paid off and exceed the state and national averages.  Marshfield Medical Center continues to have great engagement, which supports continuous improvement efforts. 

Denominators are smaller because of patients excluded due to Covid-19, which also makes bundle compliance more challenging.

“I am proud to recognize Marshfield Medical Center for their hard work improving care through this project. Wisconsin’s reputation for high-quality health care is a result of hospitals like Marshfield working together in collaboration to share innovative practices, which is clearly evident in this successful work.”
    - Sen. Kathy Bernier (R-Chippewa Falls)